The report on health and social care in England for 2017-2018 by the Care Quality Commission (CQC) is based on inspections of nearly 30,000 services.

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The inspections cover hospitals, mental health units, community nurse teams, general practice and the entire social care sector, including nursing homes, domiciliary care and residential care, making it the most authoritative published stocktake of the health and social care system.

The 134-page report, The State of Health Care and Adult Social Care in England 2017/2018, identifies examples of good and bad services, but concludes that most services provide high-quality care.

The problem, the report states, is more to do with access. For example, an estimated 1.4 million older people, one in seven people over 65, are not receiving the care and support they need.

Fragmented care

Funding is clearly crucial, but what is also important is how local services across the health and social care sectors work together. The CQC calls this the ‘integration lottery’.

1.4 million

older people in England do not have access to the care and support they need

CQC chief executive Ian Trenholm says: ‘We found that, in too many cases, ineffective coordination of services was leading to fragmented care.

‘Funding, commissioning, regulation and performance management all conspired to encourage a focus on individual organisational performance, rather than ensuring people got joined-up care based on their individual needs.’

According to the CQC report, one of the issues is the inability to navigate the system. Patients do not always ‘know where to go’ and services are sometimes ‘complicated and confusing’.

The report warns that even those working in these sectors are not always knowledgeable about the services available.

Many areas have developed single points of service access to help people navigate the system, according to the report, but these vary in terms of who can use them, with some aimed at the public, some at health and social care staff.

Nonetheless, the report points to several examples of emerging practice from integrated care hubs and acute response teams that bring services together.

Leadership plays a crucial role in developing such initiatives, the report states, adding that leadership needs to be ‘outward looking and open to developing and improving relationships with partners’ and warning that, where there is a poor culture, staff are unlikely to feel empowered or supported to think beyond their own roles.

Criticisms

The CQC also reserves some criticism for how delayed discharges have been tackled, which the government has made a priority.

40%

fall in the number of community matrons in the past eight years

Over the past year, the number of beds occupied by such cases has fallen by nearly one fifth to just under 4,700.

But the CQC warns that the push has ‘almost overwhelmed other priorities’ with inspectors identifying examples where the focus has compromised the safety of people moving through services.

These examples include people being moved out of care settings before arrangements for equipment, medicine or transport are in place for the person to return home.

The CQC report also states that the lack of seven-day services outside hospitals is still a problem.

NHS Confederation deputy chief executive Danny Mortimer agrees it is time to ‘get serious about transformation’.

Sally Bassett

Mr Mortimer says developing integrated care must be ‘central’ to forthcoming long-term planning for the NHS, while there must be certainty over social care funding from the green paper that is also due to be published before the end of the year.

‘The challenge for local health and social care systems will be to deploy combined resources in the most effective way possible to provide improved care to an older and increasingly dependent population.’

But RCN nurses in leadership and management forum chair Sally Bassett says it would be wrong to blame the managers: ‘The use of the term “poor leadership” presents an overly simplistic analysis.’

‘It is clear that, in most cases where quality fails, leadership is not the sole reason; often it is because of wider system failure.’

Ms Bassett says workforce shortages are a bigger problem, while the CQC report highlights how services outside hospital have been hit in particular.

19%

reduction in delayed discharges in the past year

While the number of nurses working in hospitals has been rising, the number of community matrons has fallen by 40% in the past eight years, while that of district nurses has dropped by 44%.

In social care, the CQC highlights the vacancy rates. Across the sector, the proportion of unfilled posts rose from 6.6% to 8% in the past year. The worst hit roles were nurses, with one in eight posts remaining unfilled.

‘The system at a national level needs to address this,’ states Ms Bassett.

INTEGRATED CARE IN ACTION

The care hub

An integrated care hub has been set up by the council and local clinical commissioning group (CCG) in Wakefield, West Yorkshire, relieving pressure on hospitals and GPs.

GPs can ring just one number or complete one e-referral form for someone with multiple needs.

The person is then sent to the hub, where nurses, occupational therapists, physiotherapists, social care staff and mental health workers can integrate the care they provide. To help manage this, a mixed team of health and social care coordinators sit together in one office and triage referrals.

An urgent care team sits with them and can go to any patient needing rapid care, for example by providing mobility equipment that day, which may prevent them having to go into hospital. In the past six months, the hub has cared for nearly 2,000 people.

Community matrons carry out immediate home visits where cases are flagged as urgent, and it is estimated that this has saved at least 400 emergency admissions.

CCG chief officer Jo Webster says: ‘People only want to tell their story once and then they want a solution.

‘Many older people don’t have a single medical condition or social care problem. They need a package of help that meets their needs and that’s what we’ve done.’

The acute response team

In Thanet, Kent, the council, local NHS and Age UK have worked together to create an acute response team.

The service brings social care coordinators, therapists, support group workers and volunteers alongside NHS specialist staff such as diabetes nurses into a single team to support people who have fallen ill and risk being admitted to hospital.

Instead of admission, the team treats and cares for them in their own home or in the community.

It is the first time that the different staff groups have worked together in this way in the area, and it is estimated that the service allowed 200 people to stay out of hospital last winter, improving health outcomes and relieving pressure on local health and care services.